Laryngeal aspergilloma: a complication of inhaled fluticasone therapy for asthma.

Darley D, Lowinger D, Plit M - Respirol Case Rep (2014)

Bottom Line:
Primary laryngeal aspergillosis in immunocompetent patients is rare.We describe a case of a 59-year-old woman with laryngeal aspergillosis thought to be secondary to long-term inhaled fluticasone therapy.Laryngeal aspergillosis may be an underrecognized complication of inhaled corticosteroid therapy.

Affiliation: Department of Thoracic Medicine, St Vincent's Hospital Darlinghurst, University of New South Wales Sydney, Australia.

ABSTRACTPrimary laryngeal aspergillosis in immunocompetent patients is rare. We describe a case of a 59-year-old woman with laryngeal aspergillosis thought to be secondary to long-term inhaled fluticasone therapy. Laryngeal aspergillosis may be an underrecognized complication of inhaled corticosteroid therapy.

fig02: Necrotic material and numerous septated fungal hyphae branching at 45 degree angles. The appearances are consistent with that of aspergillus.

Mentions:
A 59-year-old woman presented for evaluation of hoarseness which had persisted for 1 month. She was diagnosed with asthma at the age of 28 and fluticasone propionate had been administered in a daily dose of 500 mcg for many years via the use of a large volume spacer device. She previously experienced two to three asthma exacerbations annually which responded to pulse doses of oral corticosteroids. Ten years prior to the development of hoarseness, immunoglobulin E (IgE) specific antibodies to aspergillus and aspergillus precipitins were negative and a serum IgE level was 135. Previous attempts at discontinuation of inhaled corticosteroids resulted in more frequent exacerbations of her asthma symptoms and a methacholine challenge test had demonstrated significant bronchial hyperresponsiveness. At the age of 51, she was diagnosed with focal bronchiectasis in the right middle lobe which had been associated with recurrent Pseudomonas aeruginosa infection treated with courses of anti-Pseudomonal antibiotics. Her medical history also included cigarette smoking, 15 sticks/day for 7 years until the age of 26. There was no history of immunodeficiency, malignancy, or diabetes mellitus. Lung function testing at the time of presentation was normal with a forced expiratory volume in one second of 2.72 L (111% predicted). A referral was made for an ear, nose, and throat opinion and she underwent microlaryngoscopy which demonstrated a cystic lesion of the left vocal cord (Fig. 1). This was excised and the histopathology demonstrated a laryngoma with fungal colonies containing branching hyphae, consistent with aspergillus (Fig. 2). Unfortunately, the excised tissue was not sent for culture or polymerase chain reaction analysis. Recent measurements of aspergillus precipitins were negative and a serum IgE level was normal. She was treated with itraconazole as the treatment of choice, and inhaled corticosteroids were ceased. She remained on inhaled salbutamol as required, and her asthma symptoms were infrequent. Repeat laryngoscopy at 3 months demonstrated complete resolution of the lesion. Fiberoptic bronchoscopy and bronchial washings after the diagnosis of laryngoma did not demonstrate fungal elements on cytologic examination and fungal cultures were negative. Investigations for underlying B or T cell-associated immunodeficiency were normal. The patient has been followed for 18 months since the onset of vocal cord aspergillosis and there has been no recurrence of the fungal infection.

fig02: Necrotic material and numerous septated fungal hyphae branching at 45 degree angles. The appearances are consistent with that of aspergillus.

Mentions:
A 59-year-old woman presented for evaluation of hoarseness which had persisted for 1 month. She was diagnosed with asthma at the age of 28 and fluticasone propionate had been administered in a daily dose of 500 mcg for many years via the use of a large volume spacer device. She previously experienced two to three asthma exacerbations annually which responded to pulse doses of oral corticosteroids. Ten years prior to the development of hoarseness, immunoglobulin E (IgE) specific antibodies to aspergillus and aspergillus precipitins were negative and a serum IgE level was 135. Previous attempts at discontinuation of inhaled corticosteroids resulted in more frequent exacerbations of her asthma symptoms and a methacholine challenge test had demonstrated significant bronchial hyperresponsiveness. At the age of 51, she was diagnosed with focal bronchiectasis in the right middle lobe which had been associated with recurrent Pseudomonas aeruginosa infection treated with courses of anti-Pseudomonal antibiotics. Her medical history also included cigarette smoking, 15 sticks/day for 7 years until the age of 26. There was no history of immunodeficiency, malignancy, or diabetes mellitus. Lung function testing at the time of presentation was normal with a forced expiratory volume in one second of 2.72 L (111% predicted). A referral was made for an ear, nose, and throat opinion and she underwent microlaryngoscopy which demonstrated a cystic lesion of the left vocal cord (Fig. 1). This was excised and the histopathology demonstrated a laryngoma with fungal colonies containing branching hyphae, consistent with aspergillus (Fig. 2). Unfortunately, the excised tissue was not sent for culture or polymerase chain reaction analysis. Recent measurements of aspergillus precipitins were negative and a serum IgE level was normal. She was treated with itraconazole as the treatment of choice, and inhaled corticosteroids were ceased. She remained on inhaled salbutamol as required, and her asthma symptoms were infrequent. Repeat laryngoscopy at 3 months demonstrated complete resolution of the lesion. Fiberoptic bronchoscopy and bronchial washings after the diagnosis of laryngoma did not demonstrate fungal elements on cytologic examination and fungal cultures were negative. Investigations for underlying B or T cell-associated immunodeficiency were normal. The patient has been followed for 18 months since the onset of vocal cord aspergillosis and there has been no recurrence of the fungal infection.

Bottom Line:
Primary laryngeal aspergillosis in immunocompetent patients is rare.We describe a case of a 59-year-old woman with laryngeal aspergillosis thought to be secondary to long-term inhaled fluticasone therapy.Laryngeal aspergillosis may be an underrecognized complication of inhaled corticosteroid therapy.

Affiliation:
Department of Thoracic Medicine, St Vincent's Hospital Darlinghurst, University of New South Wales Sydney, Australia.

ABSTRACTPrimary laryngeal aspergillosis in immunocompetent patients is rare. We describe a case of a 59-year-old woman with laryngeal aspergillosis thought to be secondary to long-term inhaled fluticasone therapy. Laryngeal aspergillosis may be an underrecognized complication of inhaled corticosteroid therapy.